Original article
Adult cardiac
Bilateral Internal Thoracic Artery Harvest and Deep Sternal Wound Infection in Diabetic Patients

https://doi.org/10.1016/j.athoracsur.2012.11.068Get rights and content

Background

Coronary artery bypass graft surgery is superior to percutaneous intervention in diabetic patients with multivessel disease. The use of bilateral internal thoracic arteries (BITA) may provide better long-term graft patency, but the risk of postoperative deep sternal wound infection has limited its use in diabetic patients. However, studies have reported conflicting results, and require systematic evaluation.

Methods

MEDLINE, EMBASE, World of Science, and the Cochrane library were searched for randomized controlled trials and observational studies comparing the incidence of deep sternal wound infection in diabetic patients undergoing either left internal thoracic artery (LITA) or BITA harvest. We used random effect models to compare risk ratios within groups.

Results

One randomized controlled trial and 10 observational studies (126,235 diabetic patients: 122,465 LITA, 3,770 BITA) met inclusion criteria. Deep sternal wound infection occurred in 3.1% and 1.6% for the BITA and LITA cohorts, respectively. The risk ratio for deep sternal wound infection development was 1.71 (1.37 to 2.14) for BITA compared with LITA. Patients who underwent skeletonized BITA harvest had a similar risk of deep sternal wound infection compared with LITA (0.9 [0.42 to 2.09]), although pedicled harvest demonstrated increased risk (1.77 [1.4 to 2.23]). Early mortality was comparable in the LITA cohort (2.5%) and the BITA cohort (2.3%; p = 0.8).

Conclusions

The risk of deep sternal wound infection can be minimized in diabetic patients undergoing coronary artery bypass graft surgery by performing ITA harvested in a skeletonized manner with meticulous attention to preserving sternal blood flow. Pedicled harvest is to be discouraged when utilizing both ITA owing to a significant increase in the risk of postoperative deep sternal wound infection.

Section snippets

Eligibility Criteria

Randomized controlled trials (RCT) or observational studies were eligible if they met the following criteria: (1) adult human subjects; (2) patients underwent isolated CABG, either on pump or off pump; and (3) study reported deep sternal wound infection, need for reexploration for bleeding, in-hospital mortality, or 30-day mortality in a group with BITA versus LITA. Non-English language studies were excluded.

Search Strategy

MEDLINE (1950 to August 1, 2012) was searched to identify studies relevant to our

Search Results and Study Characteristics

The search identified 267 potentially relevant citations (Fig 1). After review, nine articles were eligible for inclusion. An additional two studies were included after reference list review [14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24]. The κ statistic for the final process of selection was 0.90. The studies were graded for quality as per the Newcastle-Ottawa scale. This method uses three criteria—selection, comparability and outcome—to determine the quality of the study. A star is given for

Comment

Coronary artery bypass grafting is superior to percutaneous intervention in diabetic patients with multivessel disease [26], with the ITA providing the incremental benefit [27]. The innate resistance of the ITA to atherosclerosis, intimal hyperplasia, and medial calcification [28] persists in diabetic patients, who demonstrate a tendency toward increased vasoreactivity and occlusion of saphenous vein grafts [29]. Although the use of BITA increases long-term survival [2, 3], it has also been

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